Practice-integrated care teams – learning for a better future

Abstract

Purpose – The purpose of this paper is to present a case study of one element of the integrated work which has taken place in Central Manchester, the development of multi-disciplinary Practice-Integrated Care Teams (PICT). The paper will show how working together has become a practical reality for members of these teams, and is forming the building blocks for further integration across neighbourhoods. Design/methodology/approach – This paper draws on the author’s experience of working in the PICT project from 2012 to 2014. The report will draw on the evaluation work which took place during the project, and will include reflections from others involved in the project and members of the teams. Findings – The integrated care teams which have been developed in Central Manchester have started to make significant changes to the ways that professionals work together, to the experience that patients have and to the costs of urgent care provision. Whilst there is still a long way to go, there has been significant learning from the PICT. This includes improved patient outcomes and experience. There has been an overall reduction in secondary care activity for patients the teams have been working with, with the largest reduction being in emergency admissions. Alongside this, patient feedback has reinforced the value of this personalised approach and increased overall satisfaction with the care and advice received from health and social care professionals and an improved professional experience. Evaluation has demonstrated that amongst professionals involved in the team there is a strong commitment to the principles of integrated care and that the confidence, skills and capacity of the teams have strengthened since this way of working has been introduced. As monitoring of financial impact continues to develop, cost savings from secondary care, particularly around emergency unplanned care, are encouraging. Originality/value – This paper draws on the recent experience of designing and delivering integrated care across a range of multi-agency, multi-professional partners. The model which has been developed centres around the role of general practice, and has enabled primary care to take a key role in the development of an out-of-hospital integrated care system. This has enabled community professionals such as nurses and social workers to build a much stronger relationship with general practice and enable system linkages which will be essential to the delivery of joined-up health and social care in the future. The project has been accompanied by thorough and ongoing evaluation to support the validity of the learnings which have been reported.